An Aussie in London
With the Perfect Prescription?

by E. O'Mara

Each day, at a pace that’s my own, I walk round the corner to my local chemist and I pick up 1/2 a gram (500mg) of pure, pharmaceutical heroin. I receive it in its injectable form - a white, freeze dried powder sealed and sterilized in 5 small glass ampoules, each one containing exactly 100mg of pure pharmy smack. Packaged in a small blue and white box, it’s almost disconcerting that its label merely reads ‘diamorphine hydrochloride’ and doesn’t scream, as methadone can, ‘STATE MEDICATION FOR FUCKED UP JUNKIES’. Despite the fact that heroin is available on prescription here in the UK, it is very rarely prescribed to drug users, which means, as I leave the Chemist for home each morning, I still feel like I’m clutching the winning lottery ticket under my arm – MY NUMBERS HAVE FINALLY COME UP –
And yes, it has completely transformed my life.

So is it the perfect ‘script? Well it certainly has been for me. Most of my mates wish they had the same, that if only they had a heroin script they wouldn’t have to use illicitly anymore. And as they bounce from one methadone programme to the next in their painfully slow and humiliating tour of drug clinics and Dr’s surgeries, I’m definitely inclined to agree. Years of blanket methadone prescribing for each and every user who’s ever looked for some sort of stability has landed us in a situation where poly drug use is now the norm. The low-lying brain fog of a methadone maintenance ‘script colludes to block out any joy had from a shot of heroin – nothing that a few benzos and beers won’t fix – and the cracking whip of treatment becomes a series of failures, dirty urines, punishments and secrets.

I know I’m fortunate. As an Aussie living in London, there are times when I have to pinch myself that this is real. That the long and often harrowing road of ‘substitute prescribing’ has finally come to an end – and now I’m free to think about my future. But in the small silences that fall between me counting my blessings, I can’t help but wonder whether it’s all just been a bit to little, a bit too late. I question why it has taken 18 long years to get here? Why did I have to wait until I’d been chewed up and spat out of over 10 different treatment programmes and Dr’s surgeries, of at least 4 rehabs and an uncountable number of detox attempts? Why did I have to wait until I’d ‘finished’ selling my young body to men, til I’d got sick and deeply depressed, til I’d used every vein in my body from my neck to my feet, til I’d contracted both HIV and Hep C? Yet doctors can prescribe heroin to people who are opiate dependant in the UK and indeed they have recently been encouraged to by our current Home secretary, David Blunkett. So what has happened to the UK’s famed heroin prescribing system and what parts of it should Australia attempt to import when considering it?

At the root of the famed ‘British System’ of prescribing of the 1960’s was the giving of pharmaceutical heroin, under medical supervision, to those who were heroin dependant. My ex-partner was fortunate enough to be a part of that evolution and it fared him well at the time. Now he may have to give his right leg (literally, he shoots methadone ampoules into his femoral vein) before they will prescribe him a suitable heroin script. In 1968, the clinic system was introduced which effectively took away a Dr’s discretion in the prescribing of controlled drugs. It was to be known as ‘the abolition of free prescribing’ and it was at this juncture that Britain took a fateful step, a step much more in line with America and down a road going nowhere fast.

Today, the extent and the approach towards heroin prescribing is schizophrenic. Doctors are required to apply for a special Government license, one that’s rarely issued and when it is, it’s not often used for treating opiate dependence. But although ignorance and fear are usually the building blocks on which new UK Government drug policies/initiatives are based, occasionally one sees a glimmer of hope. For British opiate users, this has appeared in the Home Secretary’s recent declaration that there would be more heroin programmes available to drug users in the near future, however the planning behind how any new programmes are to be implemented, does not seem well thought out. It appears to have fallen to a new Government think tank that has been given the task of focusing on various aspects of drug ‘misuse’ and treatment, but where this new ‘National Treatment Agency’ is headed, no one seems quite sure. Meanwhile, only 449 people currently receive a heroin prescription for opiate dependence and 96% of all opiate based prescriptions given out to British users, remains methadone.

In the 10 years since I’ve been in the UK, I’ve had the opportunity to participate in 2 very different approaches to heroin prescribing - and it has taught me a great deal about how the differing structures, regulations and nuances behind the way heroin is administered to users, is critical to the success of the programme. For example: The first heroin script I received was through a pilot project in Chelsea London, whose aim it was to study the effectiveness of prescribing either pharmaceutical heroin, or methadone in injectable form to drug users. (In the UK, methadone is available in linctus, tablet and ampoules for IM injection).

Their first mistake and one eventually admitted, was to limit the amount of diamorphine prescribed, to an unmanageably low 200mg. (The Swiss, The Dutch and others, myself included, have found 400 – 1000mg much more suitable). Pharmaceutical heroin does not have a long half life and to seriously underestimate the dosages required was to become a momentous error and one that would seriously jeopardise a person’s ability to adhere to their prescription. With a median age range of 38 and an average injecting career of 19 years, many clients at this project had other drug problems, such as crack, benzodiazepines, alcohol or cocaine which I don’t fully believe were taken on board at the time. The severely punitive clinic regulations or ‘protocols’, would bear this out. i.e. anyone caught using any other drugs or ‘topping up’ their rather limited dose, would immediately be ‘sanctioned’ by way of a 30mg reduction in ones daily prescription, reducing even further ones ability to adhere to the programme. Once ones prescription began to lower, it was practically impossible not to ‘top up’ with something else, and so clients, myself included, were locked in a constant spiral of script alterations.
A stifling clinic environment would be the clinics 2nd fundamental error, where people would be unable to talk about their other drug issues for fear of a variety of repercussions. This would lead to an even more alarming situation where clients hid serious medical issues for fear of their prescription being stopped or being transferred back to methadone linctus.

The importance of maintaining an environment where users can talk openly and honestly to their keyworkers and consultants is a crucial element in a person’s success on any drug treatment programme and this was no exception. A deeply unhappy client group had nowhere to go to complain about their treatment and attempts by users, myself included, to engage the staff in discussion, were promptly nipped in the bud. Having to attend to such a stressful and demoralising project promptly each morning in order to receive ones medication only exacerbated people’s depression and did little if nothing to improve the spirits of those attending. One minute’s tardiness and the doors would be closed in your face. We may as well have still been on ‘done.

While I have only touched on a couple of the problems this particular approach to heroin prescribing had, there were many others of which there isn’t the space to discuss in this piece. Suffice to say, that if Australia is to take on diamorphine prescribing, they would do well to take serious note of some of issues and concerns around clinic or surgery structures - by the people that actually use the service.

After 2 of the most miserable and difficult years of my life at this clinic, I left as my 200mg prescription sat at the severely reduced level of just 80mg (!!). I was deeply unhappy, and still using on top. While it may not have been a failure for everyone, they had sure made it damn hard to succeed.

Two years later, after a desperately unsuccessful period on an injectable methadone prescription, I had developed a dire crack problem, was drinking alcohol regularly for the first time in my life, and began having regular seizures from increased benzodiazepine use.

It was at this time that, after an enormous effort, I managed to secure a place at London’s famous Maudsley hospital, where there was a doctor prescribing heroin to a small group of patients. I clearly remember my sense of complete and total desperation. I felt I could not go on any longer, that if they didn’t help me I would be – I didn’t know where I would be and that was the trouble. I felt that this was my last hope, that I’d tried everything. And I begged…. Most drug users know well the feeling of someone else, a doctor, having the power of your life in their hands, every single day. A script started or terminated making the difference between life and death, or misery and hope. Sometimes you end up having to beg…

My assessment was rocky, my doctor probing. I had completely collapsed most of my veins by injecting methadone, an acidic preparation made for intramuscular injection, that the vast majority of British users inject IV. Why they haven’t developed an intravenous solution is anyone’s guess but I expect it’s for the usual reasons: ‘Don’t give them what they want’. But it’s not about want anymore. A chemical dependence is about ‘need.

Over the period of a few days, I made the uncomfortable but necessary transition from 200mg of methadone injectables, to 500mg of diamorphine hydrochloride. Converting a methadone prescription to pharmaceutical heroin is another area Australia would do well to ensure they get correct if heroin prescribing is introduced. The clinic at Chelsea relied on the inaccurate assessment that 1mg of methadone was equal to 1mg of diamorphine proving a costly error for all concerned. A more precise estimate is 1mg methadone to 3 or 4mg of diamorphine.

The method by which I was prescribed heroin this time seemed like the polar opposite of Chelsea. I was taken seriously when I said I needed more, the dosage being increased until I said I was comfortable. For me, this was at 500mg, more than double the Chelsea clinic had offered. My doctor would see me once every 2 weeks and I was to pick up my prescription at my local chemist. Back then, I felt the doors open for me for the first time. I felt in control of my use and did not have to arrange my day around clinic hours.

Although I entered the programme with multiple habits (crack, methadone, heroin and pills), having a heroin prescription was not going to sort all these issues out.  While the support of my mum who lived in the countryside had always been there, I had previously been unable to benefit from this because, like most people in treatment, I was rarely offered takeaways. Despite my mothers’ protests, it wasn’t often that I got the chance to stay with her for more than a weekend at a time. This time round however, it was precisely because my doctor recognised the importance of my mothers support and was able to assist our relationship by giving me the necessary take-aways to stay at her house, that I was able to recover so swiftly. Within 4 months, I had stabilised and had stopped using all other drugs aside from my prescription.

I have now been on my heroin script for 2 ½ years. My health has improved substantially and my HIV doctor is delighted – as is my mum and I. My moods and energy levels have improved considerably and so has my ability to contribute to life and my community. I founded and continue to work on what has become a National drug users’ magazine called Black Poppy, and I am actively involved in drug user politics, journalism and harm reduction issues. It has been a difficult journey, but thanks to my mum, my mates and the open-mindedness of my doctor, who fully engages me in my treatment decisions and doesn’t wave punishments in my face, I have stabilized and am well, for the first time in 18years of using opiates. 

Now, I have somewhat of a vested interest in the campaign towards prescribing heroin in Australia. Last year, my mum returned to Australia to live and while I would have liked to go with her, the thought of losing my heroin script after fighting so hard to get it, felt more than I could bear. I am HIV positive. There are going to be times when I will want to be near my family. Yet archaic laws in Australia forbid me from even entering the country with my prescription. How can this be legal? Anyone, on any other medication, would be permitted to continue that medication in another country but these basic human rights do not extend to drug users. The intense and totally unfounded hysteria that surrounds the prescribing of heroin to drug users sadly endures and has made the campaign to prescribe heroin in Australia a momentous task. Yet while campaigners look to the British System for guidance, it would be a mistake not to closely examine both its failings and successes. The potential for problems in importing a system that hasn’t been culturally fine tuned for the Australian using community are great because to get it wrong, Australia may lose the chance to ever attempt it again. The Swiss users have to return to their heroin prescribing clinic 3 times a day to receive their heroin, watched over as they inject by a clinic nurse. Although the Swiss programme has had incredibly positive results, would Australian users blossom under such a severe restriction of an individual’s freedom? Or if the dosage is not allowed to be adjusted to suit each individual, as occurred at Chelsea, what chance is there of success?

While there is undoubtedly a role for the prescribing of heroin to heroin users, it is important to remember how crucial the role of the heroin user is in the planning, implementation and evolution of a heroin programme. Users must be involved every step of the way and accepted, as other users of health services are, as an integral part of a programmes development, with rights, responsibilities and a mutual respect for experience.

Take the best bits out of the British system, and don’t bring the worst – it will be users that will ultimately pay. And that means their families and their communities as well.

So these days, my life might not be perfect, but it’s not perfect for all the right reasons. Now my daily concerns revolve around my work and deciding what to have for dinner and not how the hell am I going to get the money for my gear today. I may still be drug dependant, but I don’t suffer from a drug problem. I have finally been given the respect I deserve and most importantly, I’ve been given back control over my own body. I pray that one day, and sooner rather than later, Australia implements heroin prescribing – and I can come back home.

Erin O’Mara
An Aussie in London.